UROSEPSIS WITH MODS

Case History and Clinical Findings CHEIF COMPLAINTS: PATIENT CAME WITH C/O NOT PASSING URINE SINCE YESTERDAY EVENING C/O FEVER - 1SPIKE YESTERDAY MORNING 
HOPI:
 PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN HE DEVELOPED FEVER, ON AND OFF TYPE, WITH URINARY INCONTINENCE SYMPTOMS. FEVER IS HIGH GRADE, WITH JAUNDICE FOR WHICH HE TOOK TREE MEDICATION; AND FEVER WAS INTERMITTENT IN NATURE, WITH CHILLS AND RIGORS, RELIEVED ON TAKING ON MEDICATION. ANURIA SINCE LAST NIGHT PATIENT WAS BROUGHT IN GASPING STATE TO CASUALTY BY HIS ATTENDERS, AND ON PRESENTATION BP WAS UNRECORDABLE. 
PAST HISTORY:
 NOT A KNOWN CASE OF DM, HTN, CAD,CVA, EPILEPSY,TBPERSONAL HISTORY APPETITE : NORMAL DIET: MIXED BOWEL AND BLADDER MOVEMENTS : REGULAR OCCASSIONAL DRINKER FAMILY HISTORY NOT SIGNIFICANT GENERAL PHYSICAL EXAMINATION NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA VITALS TEMP : AFEBRILE PR 147BPM RR 16CPM BP : 80/60MMHG SPO2 98% AT RA SYSTEMIC EXAMINATION CVS S1 AND S2 HEARD NO MURMURS HEARD RESPIRATORY SYSTEM BAE+; NVBS + P/A : SOFT, NON TENDER; BOWEL SOUNDS POSITIVE CNS : PATIENT IS IN STUPOR NO MENINGEAL SIGNS, NO CEREBELLAR SIGNS.
Diagnosis 
 UROSEPSIS WITH MODS (AKI, ALI, HYPOTENSION); SEPTIC SHOCK AND DIC ICD 10 CODE R65.21
DEATH SUMMARY : 
A 60 YR OLD MALE WAS BROUGHT TO CASUALTY ON 25/01/23 AT 11:30 AM IN THE GASPING STATE WITH GCS:E2V1M1 WITH COMPLAINING OF ANURIA SINCE YESTERDAY EVENING 6:00 PM AND 1 FEVER SPIKE IN THE MORNING HIGH WAS RELIEVED ON MEDICATION. AT PRESENTATION SATURATION WAS 46% ON RA AND BP WAS NON RECORDABLE AND PR WAS 68BPM. PERIPHERAL PULSES WERE NOT PALPABLE AND CENTRAL PULSES ARE FEEBLE. ABG SHOW HIGH ANION GAP(METABOLIC ACIDOSIS). PATIENT WAS INTUBATED IN VIEW OF BRADYCARDIA AND FALL IN SATURATION WITH ET 7.0 CMS, CONNECTED TO MECHANICAL VENTILATOR. FLUID RESUSCITATION WAS DONE AND NORADRENALINE WAS STARTED FOR HYPOTENSION AND AFTER 1 HOUR INJ VASOPRESSIN AND INJ DOBUTAMINE WERE ALSO STARTED AS BP WAS STILL NOT RECORDABLE. PATIENT WAS TREATED WITH IV ANTIBIOTICS, IV FLUIDS AND SUPPORTIVE CARE. TRIPLE LUMEN WAS PLACED IN RIGHT FEMORAL VEIN AND INOTROPE SUPPORT CONTINUED. INSPITE OF ALL ABOVE MEASURES BP WAS NOT RECORDABLE AND AT 9:35 PM PATIENT HAD SUDDEN BRADYCARDIA AND CENTRAL PULSE WAS NOT FELT AND CPR WAS DONE FOR HALF AN HOUR; INSPITE OF ALL THE EFFORTS PATIENT COULDNT BE REVIVED AND WAS DECLARED DIED AT 10:05PM WITH ECG SHOWING FLAT LINE AND NO ELECTRICAL ACTIVITY IMMEDIATE CAUSE : UROSEPSIS WITH MODS(AKI, ALI, HYPOTENSION) SEPTIC SHOCK AND DIC ICD 10 CODE - R65.21 
ANTECEDENT CAUSE : UROSEPSIS

 Investigation
 HEMOGRAM : TC 74000 HB 11.3 MCV 104.5 MCH 33.5 MCHC 32.1 PLT 1.73 LAKH RBS 88 LFT : TB 16.14; DB 8.69;SGOT 396; SGPT 150; ALP 673; TP 5.7; ALB 2.0; A/G 0.57RFT : UREA 107; CREATININE 3.7; URIC ACID 8.0; CALCIUM 10.2; PHOSPHORUS 5.3; SODIUM 144; POTASSIUM 2.4; CHLORIDE 103 SEROLOGY- HBSAG AND HIV 1 AND 2 - NEGATIVE SERUM LACTATE - 11.7 MG/DL MAGNESIUM 2.0 C REACTIVE PROTEIN : POSITIVE(1.2MG/DL) D DIMER 130NG/ML CUE : COLOUR : PALE YELLOW APPEARANCE : CLOUDY REACTION : ACIDIC SP GRAVITY: 1.010 ALBUMIN : ++++ SUGAR: NIL BILE SALTS AND PIGMENTS : NIL PUS CELLS 6-8 EPITHELIAL CELLS 1-2 CAST- BILIRUBIN AND GRANULAR CASTS PRESENT BLOOD GROUPING AND TYPING : O +VE ABG PH 7.117 PCO2 32.1 PO2 56.2 OXIMETRY VALUES ctHb 11.6 g/dlsO2 76.3 cHCO3 (P st) 10.7 c HCO3(P) 9.9 ANION GAP 16.3 mmol/l ANION GAP K+ 20.2 mmol/l 
Treatment Given
 1) RT FEEDS - MILK 200ML 4TH HRLY; WATER -200ML - 2ND HRLY 2) INJ NORAD 2 AMP IN 46ML NS 3) INJ VASOPRESSIN 2 AMP IN 46 ML NS 4) IV FLUIDS DNS AND NS @30ML/HR 5) INJ ATRACURIUM 2CC IV/STAT 6) INJ DOBU 1AMP IN 46ML NS 7) INJ MEROPENEM 1GM/IV/STAT FOLLOWED BY INJ MEROPENEM 500MG IV/BD 8) FENTANYL 200MG(4ML) + 2AMP MIDAZ 30G(30ML) + 34ML NS @4ML/HR 9) TAB UDILIV 300MG RT/BD 10) SYP LACTULOSE 15ML RT/BD 11) TAB DOLO 650MG RT/TID 12) INJ NEOMOL 1GM IV/SOS 13) INJ THIAMINE 200MG IV/BD 14) INJ OPTINEURON 1AMP 100ML NS IV/OD

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